Care pathway: Onset to recovery

Looking at a stroke patient’s journey as a continuum or pathway enables a better understanding of the condition from onset to rehabilitation and recovery

Some 150,000 strokes affect people in the UK every year. Stroke remains the largest cause of complex disability and the fourth most common cause of death.

However, developments in stroke recognition, brain imaging and medications, as well as the introduction of structured rehabilitation programmes, have made a significant contribution to the standard of care in hospitals and the community.

This in turn is having a positive impact on patient survival. The number of stroke-related deaths has decreased by more than 40 per cent in 20 years.

Today, the patient’s journey from diagnosis to treatment and after-care is significantly more complex than it was in the 1990s. It includes a number of distinct steps, each one of which aims to optimise both treatment and patient experience.

An important advantage is that the quality of care delivered can be monitored and evaluated at each step so changes can be made to achieve best practice where they are most needed.

1. CASE ASSESSMENT

If you have a suspected stroke, you will be admitted to accident and emergency. Medical staff will want to know as much as possible about your symptoms, and will carry out assessments to find out whether you do have the condition and what might have caused it. Your blood pressure will be taken immediately. You will have blood tests to measure your sugar and cholesterol levels, and how quickly your blood clots. You will also have an electrocardiogram.

2.  SCANNING

You should receive a brain scan within 24 hours of the appearance of symptoms. This can be a computed tomography (CT) scan and/or a magnetic resonance imaging (MRI) scan. It will help determine where in your brain the stroke happened and whether this was caused by a blood clot (ischaemic stroke) or by bleeding (haemorrhagic stroke). You will be scanned within one hour of arrival if, for example, you are not fully conscious or are on certain medicines.

3. THROMBOLYSIS

If it has been confirmed, through a scan, that you had an ischaemic stroke, you may be given medicine that helps break up clots, to restore blood flow to the brain. This treatment is called thrombolysis and Alteplase is the most widely used clot-busting drug. It must be administered within four-and-a-half hours from the onset of symptoms to be effective. If you had a haemorrhagic stroke, you will not receive thrombolysis because it can make the bleeding worse.

4. STROKE UNIT

Following the initial assessment, you will be transferred to a stroke unit – a centre specialised in the management of the first 72 hours of care, which are crucial to good outcomes. Transfer should occur within four hours of arriving at A&E. Research shows that patients who are looked after in a dedicated stroke unit have a reduced risk of disability and mortality, and are more likely to be living at home one year after the stroke.

5. SPECIALIST ASSESSMENTS

In the stroke unit, you will be seen within 24 hours by a stroke specialist team. Your ability to swallow should be assessed within four hours of admission, by taking X-ray images as you swallow a bolus of barium. Most people with a stroke have difficulty swallowing, which may result in potentially life-threatening infections such as pneumonia. If the test shows your swallowing ability has been affected, you will receive specialist care to reduce your risk of developing complications.

6. OCCUPATIONAL THERAPY

You will be seen by an occupational therapist within four days of admission to the stroke unit. Occupational therapy improves the chances of returning to independent living. It does so by helping relearn or compensate for abilities that may have been lost as a result of the stroke. In addition, an occupational therapist can show you strategies to make everyday activities such as dressing or washing yourself easier, and can advise on special equipment and adaptations you may need.

7. PHYSIOTHERAPY

Physiotherapy is an essential component of stroke rehabilitation. A stroke can damage brain regions that control movement, causing weakness or paralysis, usually on one side of the body. If you have limited mobility, a physiotherapist may help you regain the ability to move, through exercise and other interventions. As part of your physiotherapy care plan, you will be encouraged to practise walking as soon as possible. Physiotherapy starts in the hospital and often needs to continue at home.

8. SPEECH AND LANGUAGE THERAPY

About half of the people who have a stroke experience difficulties with speech and language, for which they require specialist care. You may be unable to speak clearly (dysarthria) or to form and understand words (aphasia). Therapy may involve performing exercises that address the type of impairment you have to improve your ability to speak over time. A therapist can also teach you alternative ways to communicate, such as writing, drawing and using gestures.

9. MULTIDISCIPLINARY TEAM WORKING

There is overwhelming evidence, from studies and real-life experience, that a multi-disciplinary team approach to care yields the best results, in terms of patient outcomes. For this reason, stroke units have co-ordinated teams of medical, nursing and therapy staff, who have specialist expertise in stroke rehabilitation. Compared with conventional care, multidisciplinary team working for stroke which starts in the hospital and continues in the community, increases the likelihood of regaining independence, reducing the need for institutional care.

10. DISCHARGE PROCESS

Before you leave hospital, the stroke team, together with social care services, will prepare a discharge plan for you. This aims to ensure you continue to receive the treatment and support you need. It may include home visits to arrange for any practical help you may require. Depending on where you live, you may be assigned to an early supported discharge (ESD) team, who will treat you at home, enabling you to leave hospital earlier.

11. THERAPY AND RECOVERY

The recovery process from a stroke is rarely complete when it’s time to leave hospital. It usually continues for several months, either at home or in a long-term care facility after discharge. It is likely you will need to see a physiotherapist, dietician and other healthcare professionals. Support, including psychological therapy and stroke counselling, is also available. If you have financial worries, certain charity organisations may be able to help. You may also be eligible to apply for state benefits.